Patient Referral

This form is for referrals from other dentists or doctors to
Drs. Barringer & Crestetto, P,A.
901 N. Winstead Ave., Suite 130
Rocky Mount, NC 27804
Phone (252) 443-7331 Fax (252) 937-2381

Patient:
Appointment:

**Consultation Regarding:**
Third Molars	Implants	Trauma
Extractions	Orthognathic Surgery	Pathology
Preprosthetic	TMJ	Periapical Endontic Surgery

Comments:

Diagnostic Radiographs or Records being sent?Yes No

Referring Doctor

Patient referred to:

Jack R. Winslow, DDS
W. Kennon Barringer, DDS
John M. Crestetto, DDS, MD

Please Mark Appropriate Teeth for Removal or Treatment

Patient's Right

UPPER

Patient's Left

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	32	31	30	29	28	27	26	25	\|	24	23	22	21	20	19	18	17

Patient's Right

LOWER

Patient's Left

Referring Doctor's Email Address

PLEASE READ: It is recommended that patients have a consultation visit prior to scheduling for involved procedures, or intravenous anesthesia. At this consultation appointment your oral surgical problem can be evaluated, treatment options and plans discussed, and type of anesthetic selected. Your medical history will be reviewed. A determination of the fee will be made. In case of emergencies or special situations the consultation can be immediately prior to the surgical procedure

Less involved procedures, such as extractions under local anesthesia, can generally be done at the initial visit.

Print this page as a record of your submittal.
This form will be sent via an email to Drs. Barringer and Crestetto.